NCLEX Questions, Mock NCLEX RN Exam Questions, NCLEX-RN Questions, Nurselytic

Questions 158

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Extract:


Question 1 of 5

Which one of the following statements is correct when measuring the client for crutches?

Correct Answer: B

Rationale: Proper crutch fitting requires a gap of about three inches (or two to three fingerbreadths) between the crutch top and the axilla to prevent nerve damage. The elbow should flex at about 30°, and crutches extend about 6 inches laterally from the foot.

Question 2 of 5

A 22-year-old single woman was admitted to the psychiatric hospital by her mother, who reported bizarre behavior. Except for going to work, she spends all her time in her room and expresses concern over neighbors spying on her. She has fears of the telephone being 'bugged.' Her diagnosis is schizophrenia. One nurse per shift is assigned to work with the client. The primary reason for this plan would be to:

Correct Answer: B

Rationale: The client is suspicious and needs help to develop trust, which is basic to her improvement. Consistent nursing assignment fosters a therapeutic relationship.

Question 3 of 5

The most appropriate method of evaluating whether the diet of a child with cystic fibrosis is meeting his caloric needs is:

Correct Answer: A

Rationale: Consistent weight gain, even if it is slow, is an indication that the child is eating and digesting sufficient calories.

Question 4 of 5

A client with a history of chronic renal failure is receiving hemodialysis. Which assessment finding indicates a complication during dialysis?

Correct Answer: B

Rationale: Hypotension during dialysis suggests fluid removal too rapid or disequilibrium syndrome, a serious complication. Fatigue (
A), headache (
C), and stable weight (
D) are less concerning.

Question 5 of 5

A client had abdominal surgery this morning. The nurse notices that there is a small amount of bloody drainage on his surgical dressing. The nurse would document this as what type of drainage?

Correct Answer: C

Rationale: Drainage from a surgical incision is initially sanguinous, proceeding to serosanguinous, and then to serous.

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